Prior Authorization Request Forms

Not all Express Scripts Canada cardholders are covered under Express Scripts Canada’s Prior Authorization (PA) program. To find out whether a cardholder is covered under Express Scripts Canada’s PA program, contact the plan administrator (employer or insurer) first to obtain confirmation.

(Select and print the form that corresponds to the drug that has been prescribed)

If you are a patient/cardholder and you require assistance or have any questions on the Prior Authorization Program or on the Request Forms, please contact your plan administrator.

If you are a pharmacist and have any questions on the Prior Authorization Program or on the Request Forms, please contact Express Scripts Canada Provider Call Center.